MEDICARE: GONZALEZ DENTAL LAB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	292200000X	Dental Laboratory	DL 11401	FL

General Provider Information

NPI Number	:	1093188856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GONZALEZ DENTAL LAB

Provider Business Mailing Address
First Line	:	1065 NW 129TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33182-2324
Country	:	US
Telephone Number	:	305-975-1292
Fax Number	:

Provider Business Practice Location Address
First Line	:	921 SW 122ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33184-2477
Country	:	US
Telephone Number	:	305-975-1292
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. PEDRO P GONZALEZ
Credential	:
Telephone Number	:	305-975-1292

Provider Enumeration Date	:	11/02/2015
Last Update Date	:	11/02/2015

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Directions to “GONZALEZ DENTAL LAB ” Practice Location

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